Church of St. Raphael - Summer Stretch 2017 PARENTAL CONSENT FORM & INDEMNITY AGREEMENT Student/Participant Name: of Birth: / / Sex: M / F Current Grade in School: 6 th / 7 th / 8 th / 9 th / 10 th / 11 th / 12 th Parent/Guardian Name Home Address Home Phone Cell Phone Email: Please let us know your T-Shirt Size (adult sizes): S M L XL XXL Type/ of Event: Summer Stretch 2017 on July 10, 12, 25, 27 Locations: St. Raphael / New Hope Crystal Area Nursing Homes / Feed My Starving Children - Coon Rapids / Second Harvest Food Bank Golden Valley / Wild Mountain Taylors Falls / Shady Oak Beach Hopkins / Bunker Beach Water Park Coon Rapids / Valley Fair - Shakopee Times: July 10-8:00 AM-7:30 PM July 12-8:00 AM-5:00 PM July 25-8:00 AM-5:00 PM July 27-8:00 AM-8:00 PM Person in Charge: Anna Scherber Mode of Transportation to and from Event: Bus / Car Pool Cost: $150.00 per participant ($120.00 if you have a 2017 Valley Fair Season Pass) I,, grant permission for Parent or Guardian Name Child Name to participate in the above named activity and I warrant that my child is in good health. In consideration of my child s participation, I agree to indemnify the Church of St. Raphael, St and the Archdiocese of St. Paul & Minneapolis from any claims or law suits brought against the Church of St. Raphael, and the Archdiocese of St. Paul & Minneapolis by myself, my child or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney s fees or expenses incurred by the Church of St. Raphael, St and the Archdiocese of St. Paul & Minneapolis in defense of such a claim/suit. Should photos or video be taken, I give my permission for the use of my child s image and /or likeness in any promotional or other marketing activities relating to the youth ministry program of Church of St. Raphael. EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of any emergency, if you are unable to reach me at the above numbers, contact Name MEDICAL INFORMATION: Emergency Phone Number Medication my child is taking at present Family Health Plan carrier number Family Doctor Phone Number As Parent or Guardian, I agree to all of the above stated considerations and conditions. Parental Signature
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.) Medical Treatment: In the event it comes to the attention of the Church of St. Raphael its officers, directors and agents, and the Archdiocese of Saint Paul & Minneapolis, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called. Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are indicated on attached Prescription Drug & Medical Authorization Form. No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required. I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate. Specific Medical Information: The Church of St. Raphael will take reasonable care to see that the following information will be held in confidence: Allergic reactions (medications, foods, plants, insects, etc.): Does child have a medically prescribed diet? Any physical limitations? Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition: You should be aware of these special medical conditions of my child:
CODE OF CONDUCT The following are a few rules that all participants are expected to follow while participating and representing Church of St. Raphael on July 10, 12, 25, 27 of 2017. Please read and sign. I,, WILL: Printed Name of Youth Participant Treat all other persons with respect and not cause any intentional harm (physically, emotionally, or spiritually) to any person in any way. Respect the property of others, including all program facilities and property. Follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration. Be on time for all check-ins and departure time. Not have in my possession any tobacco, alcohol or any controlled illegal substance I agree that if any of these terms are violated, Church of St. Raphael can send the participant home at the participant/guardian s expense. Youth Participant Signature Parent/Guardian Signature Please return this form and the $150.00 fee to the St. Raphael Youth Ministry Office 7301 Bass Lake Rd. Crystal, MN 55428 no later than: Monday June 26, 2017
Church of St. Raphael PRESCRIPTION DRUG AND MEDICINE AUTHORIZATIONS (USE THIS FORM ONLY IF MEDICATION IS TO BE GIVEN DURING THE EVENT) Any prescriptions or over-the-counter medicine must be in the original, labeled container and the following information must be completed before medicine is given. -------------------------------------------------------------------------------------------------------------------------------------------- Student Name Name of Prescription/Medicine Prescribing Doctor Amount of Dosage Times to be Given Duration of Prescription I,, herby authorize the St Raphael Adult Parent/Guardian Chaperons to dispense medicine to Child Name as directed above. Signature of Parent/Guardian
ST. RAPHAEL 2017 4 amazing days of Service, Community, and Prayer Who: For all 6 th 12 th Grade Teens s: July 10 12 25-27 Cost: $150.00 per person ($120.00 if you have a Valley Fair Season Pass) Service: Feed My Starving Children, Local Nursing Homes, Second Harvest Food Bank Fun Activities: Wild Mountain Shady Oak Beach - Bunker Beach Water Park Valley Fair Registration Forms are at www.straphaelyouth.org or outside the Youth Room Registration Closes Friday June 26, 2017